Interventional Cardiology Education Through Structured Case Reviews

Case-based teaching has been used in interventional cardiology from the very beginning. The subspecialty of coronary angioplasty was introduced to the world by Andreas Gruentzig through a description of case reports (1). Case-based conferences including both live case transmissions and reviews of completed interesting/complex cases was the standard type of teaching by Gruentzig and subsequently his students when they returned to their respective countries/hospitals. The cases in Zurich and those after Andreas joined the lab at Emory University were almost totally case-based presentations. The live transmissions from the catheter labs via fiber optic cable to large high-definition screens in the auditorium were state-of-the-art 40 years ago. Cases were presented and the procedures demonstrated from “skin to skin,” and because the audience had little or no experience with angioplasty, all were interesting. Many composing the early wave of interventionalists got their start from these courses. Many others, upon seeing the difficulty of these cases with the early catheters we had to work with and no bail-out stenting, decided to pursue other lines of work. Without case demonstrations, no one can grasp interventional cardiology. Hartzler, Stertzer, Myler, and Katzen and other pioneers refined and expanded this practice, establishing live and taped case-based learning as integral to the education of interventional cardiologists.

Accordingly, the Transcatheter Cardiovascular Therapeutics (TCT) conference has incorporated an extensive worldwide live case transmission and case reviews program since inception, and the same model has been followed by nearly all interventional cardiology conferences around the world. For the most part though, case presentations are assigned to experienced centers and operators, rather similar to the way invited lectures are delivered by specifically invited expert faculty at scientific conferences.

To broaden participation and promote inclusivity, every scientific conference also includes (and encourages) involvement through the well-known competitive abstract submission (and peer-evaluation/scoring) process. Extending this concept to case-based participation emerge at the 10^th anniversary of the TCT symposium, following proposals from many interventional cardiology centers around the world to present their challenging clinical work and receive peer-review and advice on the techniques/technologies used, similar to other TCT sessions. This timing was likely related not only to the very broad expansion of interventional cardiology centers worldwide, but also to the advent of CD-ROMs as the way to save the cine-angiograms, which made the bulky films (that were hard to copy and mail) instantly obsolete. Given the need to still mail CD-ROMs and a separate set of paperwork to describe each case, the submission procedures were still cumbersome (and expensive) and the evaluation process lengthy. By popular demand, despite the above difficulties, such case review sessions were organized regularly at TCT, and for a brief period, the Society for Cardiovascular Angiography and Interventions (SCAI) started to organize a call for such submissions, which was also met with enthusiasm and has remained a key method of participant interaction in the annual SCAI sessions and courses ever since.

Another important technological advance enabled an important next step that further popularized challenging clinical case submissions in interventional cardiology (2). The move to web-based, exclusively paperless abstract submission (using Word-based files of scientific research) and evaluation process allowed TCT to develop a challenging case competition (using imaging/text instead of pure text submission files, of course). Not only was submission easier and inexpensive, but broader/faster scoring by many peer reviewers was also possible. The response was overwhelming and the American College of Cardiology Innovation in Intervention (ACC-i2) subsequently incorporated a similar system for case report competition for presentation at the annual ACC conference. Worldwide participation in such sessions that are now offered at many global conferences remains strong and is growing, having progressively expanded from coronary to endovascular and valve cases, and has been adapted in focused courses, supporting multiple languages and geographies.

As regular organizers of the entire process of case-based education at various conferences, we have always appreciated the educational value and the complexity/depth of the actual presentations, and are constantly attempting to further enhance their educational potential. Thousands of such cases are presented at global conferences on a yearly basis, and several websites host them with various degrees of completeness, peer-reviewed comments, and duration of online viewing. General messages encouraging case presenters to submit their case reports to subspecialty journals had rather low yield (very few publication spots were available and relatively few submissions ensued). The emergence of dedicated case report journals is yet another important development that offers a dedicated venue for these novel fascinating and highly instructive descriptions of technique and case-based learning.

Case sharing and case-based teaching have always been an integral part of TCT, and TCT 2019 was no exception. Almost 1,100 Challenging Cases were submitted and peer-reviewed by 168 individuals (mostly TCT faculty)—an average of nine grades per case submission. Eventually, over 3 days, approximately 650 cases were presented in 29 coronary or imaging sessions, 13 structural heart (valve and non-valve) disease sessions, and 8 endovascular disease sessions. The most popular countries of origin were the United States, India, Japan, United Kingdom, Italy, Bangladesh, China, Egypt, Poland, Korea, and Germany. The current issue of JACC: Case Reports represents just a small sample—those that ranked the highest—of the cases submitted and presented.

JACC: Case Reports embraced the proposal to directly recognize the many Challenging Case competition presenters at TCT 2019 for the first time. We strongly believe that many of the remarkable clinical cases from TCT 2019 reflecting the advances in interventional cardiology and structural heart disease need to be promoted and disseminated. Before TCT 2019, we agreed that we would select the best clinical cases, and these would undergo peer review according to JACC journal standards. Furthermore, we divided clinical cases not only by sections but also according to levels of expertise: beginner, intermediate, and advanced. We have also selected five clinical cases which represent major sections or advances in interventional cardiology, and these are accompanied by editorials which explain the impact of the clinical case and the bright future of structural interventions. This has been a bidirectional learning process: we learn by the authors and they learn from this review process how to improve their case presentation and eventually their manuscript.

Through this dedicated issue and collaboration between TCT and JACC: Case Reports, we hope that fellows in training will embrace clinical cases as a vehicle for education and continuous learning and the journal as a mentoring platform between fellows and senior cardiologists. We learn from each other, from our patients, and from our complications, and sharing these experiences as reflected in this issue is proof of our ongoing commitment to continuous education in cardiology.